CQC report explained · a nursing home
What the CQC found at Abbey Healthcare- Aarandale Manor
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found medicines were managed safely, risks were assessed and there were enough staff to meet people's needs. Infection control was also judged to be well managed during the coronavirus pandemic.
- Effective?
- Good
- Staff had induction, training and support. People were supported with food, drink, healthcare and choices, although some records about capacity and DoLS needed updating.
- Caring?
- Good
- This question was not covered by this focused inspection. Its previous rating was carried forward when calculating the overall rating.
- Responsive?
- Requires improvement
- This question was not covered by this focused inspection. Its previous rating was carried forward when calculating the overall rating.
- Well-led?
- Good
- Inspectors found significant management improvements, effective audits and a positive culture. They also found gaps in records for supervision, appraisals, capacity assessments, best interest decisions and DoLS.
What inspectors found, September 2020
Rated Good; inspectors found major improvements in safety, care and management, but some records and family communication still needed attention.
This was an announced focused inspection on 3 and 4 September 2020. Inspectors checked whether the home had acted on its previous improvement plan. They reviewed care, medicine and staff records, spoke with staff and relatives, and looked at infection control during the coronavirus pandemic.
The home was rated Good overall, with Safe, Effective and Well-led all rated Good. Inspectors found that people were kept safe, received medicines as prescribed, had suitable care plans and were supported by trained staff. The home was clean and had increased infection control measures.
The rating improved from Requires Improvement at the previous inspection. Earlier breaches about safe care and treatment and good governance were no longer in place. Inspectors did find some recording shortfalls, but the home provided evidence that these had been addressed after the inspection.
Safe medicines
People received their medicines as prescribed. Staff were trained and assessed before giving medicines, and records had no gaps.
“There were no gaps in recording, which provided a level of assurance that people were receiving their medicines safely.” from the report
Infection control
The home was clean and had increased cleaning, protective equipment and staff training during the pandemic.
“At this inspection we found that the home was managing infection prevention and control well especially during the COVID-19 pandemic.” from the report
Better care records
Care plans had become easier to use, with important information about people's needs easier for staff to find.
“These were simple to navigate around, with required information about people's needs and requirements easily found.” from the report
Management improvements
The home had made substantial progress since the previous inspection and was no longer in breach of the earlier regulations.
“At this inspection we found improvements had been made and the provider was no longer in breach of regulations.” from the report
Incomplete management records
needs fixingRecords did not always show that staff received supervision as often as the policy required. Staff appraisals were also not yet complete.
“Records did not always evidence that staff received the frequency of supervisions as per the provider's policy, appraisals for staff were yet to be completed” from the report
Capacity and DoLS records
needs fixingSome care plans did not include information about capacity, best interest decisions or DoLS authorisations and conditions. The home said these records were reviewed and updated after the inspection.
“Some care plans that we looked at did not contain information about the person's capacity, any best interest decisions that had been made and whether a DoLS authorisation and conditions was in place.” from the report
Family communication
minorMost relatives received regular updates, but some said communication was limited and could be better.
“One relative stated, "I don't hear a lot from the home, I ring and ask but there isn't much communication or information.” from the report
Food choices for some people
minorSome relatives raised minor concerns about dessert variety for people with diabetes and food being offered that people disliked.
“Some relatives did make some minor negative comments about the lack of variety of desserts for diabetic people and staff giving food items they dislike” from the report
- 01How do you now check that staff receive supervision and appraisals at the frequency set out in your policy?
- 02How do you make sure each person's care plan records their capacity, best interest decisions and any DoLS conditions?
- 03How often will my family receive updates, and who should we contact if communication is not enough?
- 04How do you record and act on people's food likes, dislikes and dietary needs, including choices for people with diabetes?
- 05Has the manager completed their application to register with CQC?
This was an announced focused inspection of Safe, Effective and Well-led only; the ratings for Caring and Responsive were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 25 September 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, April 2019
Rated Requires Improvement for the second time; inspectors found kind care but risks, medicines, care plans and leadership were not consistently safe or effective.
This was an unannounced inspection on 4 and 8 February 2019. Inspectors spoke with people, relatives and staff, observed care, and checked care records, medicines, training files and quality checks.
People and relatives were generally happy with the care. Inspectors saw kind interactions, good activities, food choices and support for people living with dementia. However, some people and relatives reported delays because there were not always enough staff.
The home did not have a permanent registered manager during the inspection. Inspectors found that risks were not always assessed, medicines were not always safely recorded or given, and care plans were difficult to use. There were also gaps in food and fluid records, consent records and end-of-life planning.
The overall rating was Requires Improvement, as were Safe, Effective, Responsive and Well-led. Caring was rated Good. The home was rated Requires Improvement at the previous inspection too, published in February 2018.
Kind and respectful care
Inspectors saw caring interactions, and people were generally treated with dignity and respect. Staff supported independence and knew people’s preferences.
“We observed throughout the inspection kind and caring interactions between people and care staff.” from the report
Activities and dementia-friendly surroundings
People could choose from activities including singing, quizzes, games and art. Signage and the adapted second floor helped people living with dementia find their way around.
“Throughout the inspection we observed people participating in activities which included a sing along, a quiz, a ball game and some art work.” from the report
Safeguarding awareness
Staff understood how to recognise abuse, report concerns and use whistleblowing procedures. Safeguarding concerns were reported and investigated.
“Care staff were able to explain ways in which they recognised any signs of abuse and the steps they would take to report their concerns.” from the report
Unassessed health risks
seriousSome known risks, including risks linked to diabetes, epilepsy and behaviour, did not have enough guidance for staff. Some risk assessments were not up to date.
“Risks associated with people's health and care needs had not always been assessed to ensure that people were supported and cared for safely.” from the report
Medicines safety
seriousSome medicines were not recorded as given, and stock checks found discrepancies. Some PRN guidance and documents for disguised or crushed medicines were not available where needed.
“Some people may not have been receiving their medicines as prescribed.” from the report
Care plans were difficult to use
needs fixingImportant information about people’s needs and preferences was recorded but hard to find. The regional director began changing the format during the inspection.
“Care plans were disorganised and important information about the person, their needs and preferences was not always easy to find” from the report
Unstable leadership
seriousThere was no permanent registered manager during the inspection. Management changes had slowed progress on known problems and affected the quality of care and staff morale.
“Although some progress had been made with making improvements to the home, the pace was very slow and had been impacted by the changes in management and the lack of a permanent manager in post.” from the report
Incomplete end-of-life planning
needs fixingSeveral care plans did not contain a completed end-of-life plan, and people’s wishes had not always been explored or recorded.
“For three care plans that we looked at there was no completed end of life care plan.” from the report
- 01What has changed in the risk assessments for people with conditions such as diabetes, epilepsy or behaviour that challenges?
- 02How do you now check that medicines are given as prescribed, recorded correctly and supported by the right PRN guidance?
- 03Has every care plan been moved to the clearer format shown during the inspection, and how is it kept up to date?
- 04Who is now the registered manager, and what evidence shows that the management and improvement systems are stable?
- 05Have all residents’ end-of-life wishes been discussed and recorded in completed care plans?
This was a planned, unannounced inspection that assessed all five CQC questions and looked at both the care provided and the home’s premises. This explanation was written from the published report of 5 April 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Abbey Healthcare- Aarandale Manor
3 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- September 2020Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
Read what inspectors found at Abbey Healthcare- Aarandale Manor →
- April 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
Read what inspectors found at Abbey Healthcare- Aarandale Manor →
- February 2018Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2017
Registered with the Care Quality Commission on 9 March 2017.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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